=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104707033
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON STEVE CHILDERS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2025
-----------------------------------------------------
Last Update Date | 09/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 HIDDENITE CHURCH RD
-----------------------------------------------------
City | HIDDENITE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28636-8168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-999-2768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 709 DANIELS LUMBER RD
-----------------------------------------------------
City | TAYLORSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28681-3394
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-216-4290
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------